Association of Arbitrators :: South Africa


Nomination Application Form

Dear Sir

Application for Appointment or Nomination of Adjudicator/s, Mediator/s or Arbitrator/s

In terms of the arbitration agreement/ dispute settlement clauses in the contract described below, we hereby apply to you to:

appoint:	an adjudicator
	a mediator
	an arbitrator
or
nominate a panel of:	three adjudicators
	three arbitrators
	three mediators

(please tick the appropriate boxes)

We enclose herewith the following:
1.	A non-refundable fee of R2 600.00 (Excl VAT) in respect of the Association's administrative costs. We acknowledge that appointment/nomination will not be made until payment of the required fee is made.
2.	*A copy of the arbitration agreement, or of the dispute settlement clause and supporting information taken from the contract document.
3.	We confirm that the Defendant has been issued with, and acknoledged receipt of a copy of this application.

To assist you in this matter, we set out the following relevant information:

Type of contract used (where applicable):
(e.g. White Form, JBCC, Civil Engineering, Franchise, Purchase and Sale, Partnership, General Commercial, other)
Type of subject/project:
(e.g. Office Block, House, Fast Food Outlet etc)
Location of subject/ project:
Claimant's particulars:
Name of claimant:
Address of claimant, or name and address of claimant’s representatives:
Telephone No:
Fax No:
Name of Legal Representative:
Telephone No:
Fax No:

Defendant's particulars:

Name of the defendant:
Address of defendant, or name and address of defendant's representative:
Telephone No:
Fax No:
Name of Legal Representative:
Telephone No:
Fax No:

Please give a short statement regarding the nature of the dispute :
(e.g. Breach of Contract, Workmanship, Legal Matters, Payment, Other)

Total project amount:	R
Amount disputed:	R
Approx amount of counter claim (if known):	R

Desired centre for hearing:
Language used in contract and general documentation:
Desired language for hearing:	English
	Afrikaans
	Both

Kindly indicate below the name/s of any Fellow members of this Association whom, to the best of your knowledge are currently, or have previously been, involved in this project:

We confirm that any pre-conditions to the appointment of the requested person(s) have been complied with and indemnify the Association from any claims, actions, or proceedings which may be instituted by the the Defendant against it arising out of this application.

Yours faithfully:


NAME IN BLOCK LETTERS	EMAIL ADDRESS:

Applicant's particulars

Name of applicant:
Address of applicant:
Telephone No:
Fax No:

Details and methods of payment to the Association

1.	PAYMENT INTO BANK ACCOUNT
	Name of Account	Association of Arbitrators
	Bank	First National Bank
	Branch Code	260 950
	Account No	51323105572
	*If using this method of payment IT IS ESSENTIAL THAT YOU FAX US A COPY OF THE DEPOSIT SLIP TOGETHER WITH RELEVANT REFERENCES.*


2.	PAYMENT BY CREDIT CARD
	Kindly complete the following and fax back to the Association:
	Credit Card Number:
	Type of card:
	Expiry Date:
	Amount:
	Card Holder's Name:
	Telephone No:
	Fax No:

	*Please attach proof of payment


	*Please attach a copy of your contract